Secondary interventions in patients with autologous arteriovenous fistulas strongly improve patency rates

Abstract

The reporting of endovascular intervention within an arteriovenous fistula or graft has changed over the last several years due to code bundling. With the recent creation of the lower extremity endovascular arterial intervention codes (CPT codes 37220-37235), coding for diagnosis and treatment of a lower extremity hemodialysis grafts has become even more difficult. A diagnostic fistulagram in either the arm or the leg is reported using CPT code 36147. This includes catheterization of the arteriovenous access and imaging from the arterial anastomosis to the superior vena cava (SVC) in the upper extremity and the inferior vena cava (IVC) in the lower extremity. It also includes all nonselective catheter manipulation for diagnostic imaging from the hemodialysis graft to the central veins. The length of arteriovenous access from the arterial anastomosis up to and including the axillary vein in the upper extremity is termed the “hemodialysis circuit.” In the lower extremity, the “hemodialysis circuit” extends from the arterial anastomosis up to and including the common femoral vein. Only one intervention may be reported within the “hemodialysis circuit” regardless of the number of lesions addressed. Typically, balloon angioplasty in the “hemodialysis circuit” is designated as a venous intervention and requires CPT codes 35476/75978. If a stenosis is identified at the arterial anastomosis of a hemodialysis access, balloon dilatation of this lesion should be labeled as an arterial angioplasty instead of venous. In the arm, CPT codes 35475/75962 are submitted to the insurance carrier. Since only one therapy may be reported in the “hemodialysis circuit,” the arterial anastomosis angioplasty includes treatment of all additional lesions in that segment of the vasculature up to the central veins. Endovascular intervention within the central veins (subclavian vein to SVC in the arm and external iliac vein to IVC in the leg) may be reported as stand-alone therapy or in addition to treatment within the “hemodialysis circuit” using the venous angioplasty coding 35476/75978. In the lower extremity since January 1, 2011, angioplasty of the arterial anastomosis requires use of the bundled lower extremity femoral-popliteal artery angioplasty CPT code 37224. Given that both CPT codes 36147 and 37224 have a catheterization bundled within their descriptions, reporting both would allow for “double dipping” on the work of a single catheterization. If a diagnostic fistulagram is performed in a lower extremity hemodialysis access and an angioplasty is performed at the arterial anastomosis with the superficial femoral artery, CPT codes 75791 and 37224 are reported. CPT code 75791 encompasses the diagnostic imaging of the “hemodialysis circuit” without a catheter component. If a diagnostic fistulagram is performed in a lower extremity hemodialysis access and an angioplasty is performed at the arterial anastomosis with the superficial femoral artery, but this intervention requires placement of an additional catheter in the opposite direction through the hemodialysis access, CPT codes 36147 and 37224 are reported. In this latter example, the first catheter is contained within CPT code 37224 and the additional catheter is part of CPT code 36147. If a diagnostic fistulagram is undertaken followed by percutaneous hemodialysis graft thrombectomy and then angioplasty at the arterial anastomosis with the superficial femoral artery, CPT codes 75971, 37224, and 36870 are appropriate if done through one catheter puncture. If two separate and distinct catheterizations are required to ensure patency, the additional puncture translates into CPT codes 36147, 36870, and 37224 similar to the situation described above. If a diagnostic fistulagram is performed in a lower extremity hemodialysis access, and an angioplasty is performed both at the arterial anastomosis with the superficial femoral artery as well as in the outflow on a common iliac vein, CPT codes 75971, 37224, 35476, and 75798 are reported. If this specific intervention requires placement of an additional catheter in the opposite direction through the hemodialysis access, CPT codes 36147, 37224, 35476, and 75798 are applicable. Secondary interventions in patients with autologous arteriovenous fistulas strongly improve patency ratesJournal of Vascular SurgeryVol. 54Issue 4PreviewNowadays, as a result of more liberal selection criteria, dialysis-dependent patients have become substantially older, more likely to be female and diabetic, and have more comorbidity. The 1-year primary patency rates of arteriovenous fistulas (AVFs) are poor. To improve these results, several secondary interventions can be performed. The aim of this study was to evaluate the results after secondary interventions in patients with an upper extremity AVF. Full-Text PDF Open Archive